Thromboprophylaxis for Patients with High-risk Atrial Fibrillation and Flutter Discharged from the Emergency Department

Abstract

IntroductionMany patients with atrial fibrillation or atrial flutter (AF/FL) who are high risk for ischemic stroke are not receiving evidence-based thromboprophylaxis. We examined anticoagulant prescribing within 30 days of receiving dysrhythmia care for non-valvular AF/FL in the emergency department (ED).MethodsThis prospective study included non-anticoagulated adults at high risk for ischemic stroke (ATRIA score ≥7) who received emergency AF/FL care and were discharged home from seven community EDs between May 2011 and August 2012. We characterized oral anticoagulant prescribing patterns and identified predictors of receiving anticoagulants within 30 days of the index ED visit. We also describe documented reasons for withholding anticoagulation.ResultsOf 312 eligible patients, 128 (41.0%) were prescribed anticoagulation at ED discharge or within 30 days. Independent predictors of anticoagulation included age (adjusted odds ratio [aOR] 0.89 per year, 95% confidence interval [CI] 0.82–0.96); ED cardiology consultation (aOR 1.89, 95% CI [1.10–3.23]); and failure of sinus restoration by time of ED discharge (aOR 2.65, 95% CI [1.35–5.21]). Reasons for withholding anticoagulation at ED discharge were documented in 139 of 227 cases (61.2%), the most common of which were deferring the shared decision-making process to the patient’s outpatient provider, perceived bleeding risk, patient refusal, and restoration of sinus rhythm.ConclusionApproximately 40% of non-anticoagulated AF/FL patients at high risk for stroke who presented for emergency dysrhythmia care were prescribed anticoagulation within 30 days. Physicians were less likely to anticoagulate older patients and those with ED sinus restoration. Opportunities exist to improve rates of thromboprophylaxis in this high-risk population.

Prescribing of oral anticoagulants in the emergency department and subsequent long-term use by older adults with atrial fibrillation

“…52 Because emergency phys icians are not in a position to follow patients, they rarely initiate long-term medications. This may explain the low rate of oral anticoagulant initiation in our study (18.9%; similar to other North American studies 47,53,54 ). For many patients, treatment with acetylsalicylic acid may have been considered adequate: until 2012, guidelines endorsed this agent for patients with CHADS 2 score of 0 or (possibly) 1.…”

“…Rates of oral anticoagulant initiation were much lower for patients who left the emergency department in sinus rhythm than for patients who left in atrial fibrillation, similar to results from the PINNACLE registry and other studies. 46,47 This finding suggests the need to educate emergency physicians about use of oral anticoagulants regardless of atrial fibrillation type (paroxysmal v. persistent or permanent). Discontinuations and nonadherence were modestly more frequent in the emergency department prescription group; however, at all time points the proportion of patients without stroke protection was much higher in the noprescription group.…”

Just Missing the Mark: Discharging High-risk Atrial Fibrillation / Flutter without Thromboprophylaxis

“…Furthermore, only 60.3% of patients were given patient education material on AF in their discharge instructions. 19 …”

Stroke Prevention for High-Risk Atrial Fibrillation in the Emergency Setting: Differences Between Canada and the United States

“…4 This high rate of follow-up may explain, in part, the relatively low frequency of ED OAC prescribing (27%) to high-risk patients who presented without OACs. In explaining their reasoning for withholding thromboprophylaxis, physicians often said they were deferring the decision to their outpatient colleagues.…”